A Very Good Week In Healthcare Thought: Four Developments To Feel Good About

This was an unusually positive week in healthcare, and in the thinking around healthcare; here are four recent developments to feel good about.

1. Transformative NEJM series reframing conflict of interest debate

In the last three issues of the New England Journal of Medicine, cardiologist and writer Lisa Rosenbaum offers a considered reappraisal of our often reflexive, often indignant reaction to specific types of perceived conflicts (especially those involving industry), and suggests a more nuanced approach might benefit patients and science (Part I; Part II; Part III). Rosenbaum’s absolutely right, of course, and it’s difficult to imagine anything that could more profoundly or more positively inflect translational research, and increase the likelihood of significant clinical impact.

Dyed-in-wool critics are likely to remain unmoved; to paraphrase Upton Sinclair, it’s hard to get people to understand something when their careers – and, often, it seems, their righteous self-regard – depend upon their not understanding it. However, Rosenbaum’s essay is sure to resonate with what might even be the silent majority of academic physicians, scientists, and patients who recognize the potential benefits of less stigmatized interactions with industry experts, but who, thus far, have been too intimidated to speak out. Presumably, Rosenbaum’s exceptional courage in writing this eloquent piece will similarly empower many of her readers. (See also this 2010 commentary about "White Hat Bias.")

(Disclosure/reminder: Harvard professor Tom Stossel and I originally coined the term “pharmascold,” a descriptor introduced in the second installment of the series and cited again in the third installment. I currently work in industry, at a genomic data management company; my writing about the need to engage university and industry talent collaboratively began while I was still in academia.)

TIE scholars consistently offer thoughtful commentary around the economics of healthcare. This week, Bill Gardner shared a thoughtful post connecting issues the military has encountered as a result of insisting on too many metrics, and suggests healthcare may be similarly afflicted. (I’ve discussed our “metrics fetish” here, concerns about certification metrics here, and how businesses may excessively rely on metrics here.)

While many have questioned the relevance of individual metrics, or the wisdom of insisting on particular process metrics, Gardner is actually making a different, and I think even more important point here: you can’t look at individual metrics in a vacuum. There’s an opportunity cost each time we’re compelled to comply with specific metrics, and so even if each of these metrics individually makes sense, there’s an interaction effect, and collectively, something is lost.

A better alternative, Gardner suggests (citing a recent paper by Blumenthal and McGinnis), is to choose metrics extremely parsimoniously – pick as few as possible, and make sure these “core metrics” that “are feasible to measure and maximally affect progress.” Yes, there’s a bit of an “assume a can opener” feel to this, but in explicitly acknowledging the harms of excessive well-intentioned metrics, it seems like a major step in the right direction.

3. Thoughtful exploration of the Apple Watch in applications including cancer

Some -- including my intrepid Tech Tonics partner Lisa Suennen -- were dismayed by the recent controversy involving Jeb Bush, Debbie Wasserman Schultz, and the Apple Watch (he used it to highlight potential of consumer-focused healthcare, she pointed out “I had cancer. There’s no app for that”). In contrast, I find myself tremendously encouraged by two reports this week that the Apple Watch is now being employed – in a research setting – to help oncology patients.

“Southern New Jersey’s MD Anderson Center at Cooper is setting up a program for 30 of its breast cancer patients that equips them with Apple Watches to help them self-manage their treatment as well as stay better connected to their care team and each other.”

Meanwhile, according to Stephanie Baum of MedCity News, King’s College in London has embarked on an effort to evaluate whether Apple Watches can improve medication adherence in oncology patients, and understand how patients are reacting to their treatments.

Both pilot programs seem to be tapping into a pair of acknowledged, unmet needs in medicine – better understanding the patient experience (including in cancer – see here), and improving communication between patient and the care team. If digital health technology in general, and the Apple Watch in particular, can advance these goals – that would be an outcome I’m sure both Bush and Wasserman Schultz would happily embrace.

President Obama’s Precision Medicine Initiative may have garnered bipartisan support, but it’s also elicited less favorable reviews from a range of critics who are concerned that the promise has been overstated (see this post by my Forbes colleague Michael Millenson, and this much-discussed NYT op-ed).

The latest addition to this takedown oeuvre comes from David Dobbs, an experienced science reporter who argues, in Buzzfeed, that “genetic research overpromises and underdelivers on actionable knowledge.” The debate isn’t new, of course, and the case Dobbs is advancing was most famously made in an essay geneticist Richard Lewontin penned for the New York Review of Books in 1992. In this classic, Lewontin opens with a definition of the word “fetish,” approvingly cites Adelaide from Guys and Dolls (“You promise me this, you promise me that”), and ultimately asks whether science (and in particular, The Human Genome Project) has taken to worshipping DNA and the reductionist worldview that often accompanies it.

In a similar spirit, Eric Topol, Chief Academic Officer of Scripps Health, shared (also via twitter) a list touting the many accomplishments of genomics, from non-invasive prenatal testing (a great example, in my opinion) to drug discovery (a promising work in progress) to pharmacogenomics (many examples but often overstated clinical impact) to impacting the taxonomy of disease (profound impact in oncology, less so, thus far, in many other important conditions – see here).

As noted earlier, I work at a genomics company; we are involved in efforts touching each of these areas. Not surprisingly, I deeply believe in the promise of genomics, and beyond that, I’ve seen its ability to impact the care of patients and our understanding of disease. I’m probably a lot more impressed than Dobbs by the progress that’s been made to date; every day, I’m amazed by what’s now possible, by what has become routine, and by what soon will be.

Even so, I worry a lot about the dangers of excessive hype, and recognize it tends to lead to the just sort of intense disillusionment that Dobbs (“we basically know diddly-squat”) and others express.

The wonderful writer Alexis Madrigal perhaps captured this dynamic best in a brilliant Atlantic piece he wrote last year about big data in the context of Google Flu Trends and big data. He observed,

“New technology comes along. The hype that surrounds it exceeds that which its creators intended. The technology fails to live up to that false hope and is therefore declared a failure in the court of public opinion.

Luckily, that's not the only arena that matters."

Similarly, for genetics, the hope is that continuing to drive hard on the science will deliver more results that unassailably speak for themselves, and achieve an impact at once palpable and self-evident. Articulate critics like Dobbs pointedly remind us of the difficult work that still remains to be done.